OBSTERTRICS DIABETES IN PREGNANCY Carbohydrate Metabolism in Early Pregnancy  Hormonal alteration: Increased estrogen & progesterone  Beta cell hyperplasia

 Increased insulin secretion  Effects  Tissue glycogen storage  ↓ Hepatic glucose production  Peripheral glucose utilization  ↓ Fasting plasma glucose Carbohydrate Metabolism in Late Pregnancy  Hormonal change  Human placental lactogen (HPL)  Prolactin  Cortisol  Placental growth hormone  Tumor necrosis factor  Leptin  Effects  Insulin resistance  “Diabetogenic”  ↓ Glucose tolerance  ↓ Hepatic glycogen stores  Hepatic glucose production  Metabolic change: Facilitated anabolism during feeding, accelerated starvation during fasting to ensure glucose & amino acids to fetus Normal Maternal Glucose Regulation  Maternal tendency to develop hypoglycemia between meals & at night while fasting  Levels of diabetogenic placental steroid & peptide hormones rise linearly throughout the 2nd & 3rd trimesters: Tissue resistance to maternal insulin  Progressive maternal insulin resistance requires augmentation in pancreatic insulin production to maintain euglycemia  Failure to augment pancreatic insulin production results in maternal & fetal hyperglycemia Classification of Diabetes during Pregnancy (NDDG)  Pregestational Diabetes  Type I ( Insulin deficient): Autoimmune disease  Destruction of pancreatic β cell  No insulin production  Ketoacidosis  Insulin deficient  Type II (Insulin Resistant)  Resistance to insulin  Hyperglycemia  Hyperlipidemia  Gestational Diabetes: Type III Pregestational Diabetes type I & II Characteristics Type I Ketoacidosis Frequent Age at onset < 40 years old Body habitus Lean HLA type DR3, DR4 Immune markers ICA, IAA Type II Rare > 40 years old Obese None None

 Intermediate stage between normal glucose homeostasis & diabetes  IFG: Fasting plasma glucose 110mg/dl to 126mg/dl  IGT: 2 hour plasma glucose 140mg/dl to 199mg/dl Overt Diabetes  Classic signs & symptoms: Polydipsia, polyuria & unexplained weight loss plus…  Random plasma glucose >200mg/dl or  Fasting plasma glucose >/= 126 mg/dl or  2 hour plasma glucose >200mg/dl during a 75gm OGTT Gestational Diabetes Mellitus  Glucose tolerance that begins or is first recognized during pregnancy  Arises from significant maternal insulin resistance  Preclinical Type II diabetes, unmasked by the hormonal stress of pregnancy  Screening  Low Risk  24-28 weeks  50gm Glucose challenge test  Threshold value: 130 mg/dl  High Risk  1st trimester screening (Any time it is discovered, request tests immediately)  100gm OGTT or 75gm OGTT  if normal repeat at 24-28 weeks  100 gram oral glucose tolerance test (OGTT) mg/dL mmol/L Fasting 95 5.3 1 hour 180 10.0 2 hour 155 8.6 3 hour 140 7.8 Any 2 values elevated = GDM  High risk  Maternal age >35yrs  Previous macrosomic infant  Previous unexplained fetal demise  Previous pregnancy with GDM  Family history of DM  Obesity  Glucosuria  Fetal effects  Abortion  Congenital anomalies: Cardiac & neural tube defects (Spina bifida)  IUGR: Because of vasculopathy  Fetal obesity  Birth injury: Associated with macrosomia  Preterm delivery  Unexplained fetal death  Maternal effects  Diabetic Nephropathy  Diabetic Retinopathy  Diabetic Neuropathy  Preeclampsia  Ketoacidosis  Infections  Neonatal effects

Impaired Glucose Tolerance & Impaired Fasting Glucose CHRABI Page 1 of 2

0. nephropathy.40%  Given as 3 meals & 3 snacks daily  Insulin therapy  Insulin does not pass the placenta  Maintain CBG levels as close to normal  1st trimester: 0. contraction stress test CST) & uterine artery Doppler velocimetry Timing of Delivery CHRABI Page 2 of 2  Early delivery  Vasulopathy.7 .  Once active labor begins or glucose levels decrease to <70 mg/dl.2 u/kg/d  Oral hypoglycemics: Not recommended because it can pass the placenta & cause fetal hypoglycemia & teratogenic effects  Monitoring of glucose control  Capillary glucose monitoring  Fasting: </= 95 mg/dl  Premeals: </=100 mg/dl  1 hour PP: < 140 mg/dl  2 hour PP: < 120 mg/dl  Mean Capillary glucose levels: 100 mg/dl  Hgb A1c . Respiratory Distress Syndrome: Delays pulmonary maturity  Hypoglycemia immediately after birth: High glucose in maternal blood  High glucose in fetal circulation  High insulin  With the withdrawal of continued support of glucose source once delivered  Hypoglycemia  Hypocalcemia  Hyperbilirubinemia  Cardiac Hypertrophy  Childhood Obesity  Childhood Impaired Glucose Tolerance Management of Diabetes during Pregnancy  Preconceptional care  Metabolic control prior to pregnancy  Monitoring of capillary blood glucose (CBG) levels  Pre meals: 70 .50%  Proteins: 20%  Unsaturated fats: 30 . biophysical score (BPS). non-stress test (NST).8 u/kg/d  2nd trimester . Breast feed  Yes!!! DUHAWEE HAPPY BIRTHDAY BEEEE…MWAH!!! .100 mg/dl  1 hr post-prandial: < 140 mg/dl  2 hr Post prandial: < 120 mg/dl  Hemoglobin A1c: Represents 1-2 months level of blood glucose  Smooth glucose control using insulin  Folate.1. the infusion is changed to 5% dextrose & delivered at a rate of 100-150 cc/hr to achieve a glucose level of 100 mg/dl  Glucose levels are checked hourly.0 u/kg/d  3rd trimester .  Intravenous infusion of normal saline is begun. prior stillbirth & poor glucose control  Amniocentesis for lung maturity  Expectant management  Good glucose control  Not recommended beyond the estimated due date Insulin Management during Labor & Delivery  Usual dose of intermediate-acting insulin is given at bedtime.8 -1.  Morning dose of insulin is withheld.25 U/h if glucose levels exceed 100 mg/dl.0.0.9 . 400 ug/day: 1 month prior to conception & all throughout 1st trimester Diabetes in Pregnancy  Diet  Normal body weight: 30-35 kcal/kg/day  Obese: 24 kcal/kg/d  Caloric composition:  Complex carbohydrates: 40 .6% Fetal Surveillance  Accurate dating  Congenital Anomaly Scanning  Monitoring of fetal growth  Antepartum Fetal Monitoring: Fetal movement counting (FMC).  Regular (short acting) insulin is administered by intravenous infusion at a rate of 1.

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